SystemCHANGE: An RCT for Medication Adherence in Adult Kidney Transplant Recipients With kidney transplant (KT) recipients as our exemplar population, our goal is to develop and test interventions that increase medication adherence in chronically ill adults. Among adult KT recipients, non-adherence to immunosuppressive medications (MNA) is the leading predictor of poor outcomes, including rejection, kidney loss, and death. An alarming one-third of KT patients experience MNA even though the problem is preventable. Adherence intervention studies have proven marginally effective for those with acute and chronic illnesses and ineffective for adult KT recipients. Using a randomized controlled trial design with an attention- control group, this R01 will test an innovative 6-month SystemCHANGE intervention to enhance immunosuppressive medication adherence in adult non-adherent KT recipients. This intervention shows great promise for increasing adherence with a large effect size of 1.4 in our pilot study. Grounded in the socio- ecological model, SystemCHANGE seeks to systematically improve medication adherence behaviors by identifying and shaping routines, involving supportive others in routines, and using medication taking feedback through small patient-lead experiments to change and maintain behavior. Medication adherence will be measured by electronic monitoring. Medication adherence persistence will be examined by evaluating the difference between the two groups during the 6-month maintenance phase. Mediators and moderators of medication adherence will be examined. Health outcomes will be compared and a cost-effectiveness analysis will be conducted.